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Correcting Pediatric Chest Wall Deformities

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Repairing, Regrowing and Remodeling
 
MADISON - Pectus excavatum, or funnel chest, is a disorder that looks as though it should be a greater threat to health than it actually is. The abnormal growth of bone and cartilage in the anterior chest wall, producing a caved-in appearance that may deepen as the child ages, may cause few to no problems for breathing or heart function.

That is not to say, however, that it has no affect at all.

"Funnel chest often has a big impact on a child's self-esteem and outlook on his or her own body," says Dennis Lund, MD, a pediatric surgeon with UW Health and surgeon-in-chief at the American Family Children's Hospital. "These are young men who won't take their shirts off at the beach or at the gym, and won't look at themselves in a mirror."

Pectus excavatum occurs in varying degrees in about one in 300 to 400 births, and is three times more likely in boys than in girls. There appears to be a genetic component, as more than half of children with funnel chest have at least one immediate family member who also has the disorder. It is also loosely associated with some respiratory disorders, Marfan's disease and scoliosis.

While more than half will be diagnosed within their first year, little can be done immediately to correct the deformity. For some children, the depression is small and does not deepen over time, making corrective measures unnecessary.
 
For others, the sunken chest may cause breathing problems or heart murmurs, and often takes a toll on a growing child's body image. Once these children hit their early teens and grow out of the pliable bone structure of childhood, surgical options can restore a more normal chest appearance.
 
"Traditionally, correcting funnel chest entailed a four-hour surgery to remove several ribs, elevate the breastbone and set in a straight metal bar to keep the chest's shape as the new cartilage grows," says UW Health pediatric surgeon Aimen Shaaban, MD. "It was a 'cut and let grow back' approach, and it still works for some kids. Having a less-invasive option, however, gives kids and parents a choice."

Less Invasive Funnel Chest Approach: The Nuss Procedure
 
That less invasive option is the Nuss procedure, named for Virginia physician Donald Nuss, MD. This 60- to 90-minute operation involves inserting a curved steel bar through a small incision in the side of the chest, under the sternum, and out through an incision on the other side. The bar is then rotated to push the chest outward, and affixed to lower ribs. The incisions are closed, leaving minimal scarring.

"The bar stays in much longer in the Nuss procedure - about three years, compared to six months for the straight bar," Dr. Lund says. "We're remodeling instead of removing and regrowing, which takes awhile."
 
Recovery time is about the same for both procedures, roughly four or five days. Removing the straight bar requires outpatient surgery; removing a Nuss bar is a one-night hospitalization.

"A lot of parents like the Nuss procedure because it is less invasive," says Dr. Shaaban. "But I have to remind them that it is still serious surgery, and it might not be right for every child."

Both Dr. Lund and Dr. Shaaban recommend the straight bar approach for teens who are particularly active, such as football players, horseback riders or hockey players, because the bar is left in for less time, allowing them to return to their sport more quickly. It is also more effective for cases of severe asymmetry or complex deformities. Overall, though, about two-thirds of the 15 to 20 pediatric chest deformity surgeries performed each year at UW Health use the Nuss procedure.

Pectus Excavatum Referral Encouraged Soon After Diagnosis
 
Dr. Lund, Dr. Shaaban and incoming pediatric surgeon Peter Nichol, MD, encourage physicians to refer children with pectus excavatum for a consultation as soon as it is diagnosed, so parents can have plenty of time to consider their range of options - which for many includes the option of doing nothing.

"You can be a world-class athlete with this kind of chest deformity. It does not hold you back from a healthy, active lifestyle," Dr. Lund says. "But at the same time, you can't underestimate the value of a young person feeling good about his or her body. I have yet to ask a teenage boy if he was glad he had the surgery and not hear a 'yes.'"

For more information about pediatric surgery options at UW Health, call (608) 263-6420.
 
Date published: 4/28/2008